Breast Cancer: The Most Common Questions After Surgery
Kenneth W. Kotz, MD
Following the disbelief and anger of being told you have breast cancer is the confusion involved when your surgeon refers you to the medical oncologist. If you are recovering from major surgery, which was successful in removing the cancer, then why would your surgeon send you to hear about getting additional treatment? To answer this question will involve an explanation of how cancer recurs followed by what details the oncologist will want to know about the cancer. Subsequently, the potential treatment choices can be reviewed.
Why Would Treatment Be Recommended After Surgery?
The ability of cancer cells to travel to distant organs in the body is what sets them apart from normal cells. This movement of cells is related to the inherent behavior of a cancer and is not, as commonly misconceived, a result of the biopsy itself or exposing the tumor to air during surgery. A cancer cell which has migrated to another organ in the body can be thought of as a seed. This distant seed is too small to be detected by any test and would remain in the body even after a successful operation on the breast. When the dormant seed begins to grow, a breast cancer recurrence would ultimately be diagnosed. In fact, the direct relationship between the originally treated breast cancer and a breast cancer relapse, even many years later, can be proven by showing that the original cancer cells from the breast biopsy appear identical to the distant cells obtained years later from another organ. For example, a liver biopsy, which normally should only contain liver cells, might identify breast cells, a situation referred to as "breast cancer in the liver" rather than "liver cancer".
The idea of killing distant and dormant cancer cells with medications to prevent a cancer relapse is called adjuvant therapy. On average, patients who receive the recommended adjuvant therapy will fare better than those who do not receive it. However, not every individual will benefit from adjuvant therapy. Thus, while adjuvant therapy is beneficial on the whole, there are going to be individuals who were destined to either do fine without it or who do not benefit from it. To optimally tailor the available treatments, oncologists will want to know a number of features about the cancer.
What Should I Know About My Cancer?
After surgery for breast cancer, a visit to the medical oncologist will usually involve a discussion about the particular features of the patient's cancer. This information will be used to both assess the risk of the cancer returning as well as determine the potential treatment options. These important features include the lymph node status, the size of the cancer, the grade, the estrogen receptor and the Her-2-neu status.
Lymph nodes, which act as filters all over the body, can trap cancer cells and in breast cancer the relevant lymph nodes are located in the arm pit. These particular nodes are important because a breast cancer that has spread to these lymph nodes is more likely to also have spread to other areas of the body. The size of the cancer is also directly related to the likelihood that the cancer has spread. These two features, the number of cancerous lymph nodes and the size of the primary cancer, are what determines the patient's "stage", a useful way to assign a number from 1 to 4 to describe how advanced the cancer is. "Stage" should not be confused with the "grade", a separate number found on the pathology report which is used to predict the aggressiveness of a cancer based on the appearance of the cancer cells in the microscope.
Breast cancers can also be characterized by the presence or absence of two additional markers called the estrogen receptor and Her-2-neu, utilizing the terms "positive" or "negative", respectively. Sophisticated genetic-based tests are now enhancing the ability to predict which cancers may relapse. One such test, called Oncotype DX, is currently only proven for estrogen receptor positive patients whose lymph nodes show no cancer.
What Are the Treatment Choices After Surgery?
Once armed with all of this information, it is still a complicated task to decide who needs adjuvant therapy, and if so, what therapy to offer. The decision can be simplified by considering three questions. What are the chances of cure with surgery alone? What are the chances of cure if adjuvant therapy is given? What are the dangers and side effects of the therapy?
There are currently three classes of drugs available to improve the outcome of women with breast cancer. The categories include hormonal therapy, chemotherapy and biologic therapy. Some, none or all of these could be recommended.
Hormonal therapy, which is the opposite of hormone replacement therapy, includes anti-estrogens such as tamoxifen or aromatase inhibitors (there are three available). Hormonal therapy is offered to women whose cancers are estrogen receptor positive. The decision to use chemotherapy is complex but is most commonly offered to women whose lymph nodes had cancer, who tumors were estrogen receptor negative, or other situations where the cancer recurrence risk is considered high. Biologic therapy is the newest category and currently only includes trastuzumab (Herceptin) which could be thought of as a "smart bomb" against those cancers which are Her-2-neu "positive".
It is well established that the cure rates are the same with mastectomy versus lumpectomy when the latter is followed by radiation. Many women think that having a lumpectomy means chemotherapy and having a mastectomy means avoiding chemotherapy. In fact, the type of operation performed is not relevant to the choice for adjuvant therapy which, as explained above, is based on the stage, grade, estrogen receptor, etc.
The visit to the medical oncologist after breast cancer surgery can be confusing, stressful and scary. The information discussed herein should help a patient navigate through the decision-making process. It is this very complexity that reflects the constantly improving positive impact we are having on the lives of our patients.